2011 Plan Description

8/8/2019 2011 Plan Description

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convenient

plan

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2011 Enrollment Kit

Rx DrugsDoctorsHospitals

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Health Care to Fit Your Needs… now that is peace o mind

At UnitedHealthcare we realize more than ever the importance o aordable health care

coverage. We are dedicated to helping you make the right choices by providing quality, cost-

eective health care solutions. As one o the largest and most recognized health carriers in

the United States, you can be condent we will be here

when you need us.

INSIDE THIS BOOKLET:

• Understand the basics ofMedicare Advantage

• Learn how our plans can benet you

• View plan details and how theycompare to your Original Medicare

• Start your application process

• Continue on your path to good health

Thank you or your interest in this plan. The world o Medicare can be conusing, but we’re hereto help. Together we’ll nd a plan that’s right or you.

Sincerely,

Thomas S. Paul

Chie Executive Ofcer, UnitedHealthcare Medicare Solutions

We’re Here For You

We Make Health Care Simple… and provide the answers you need

Talk with your local sales agent. Health care is personal. Your agent will

answer your questions and help you enroll.

Go online: <WebsiteAddress>.

I you don’t have a local sales agent, call SecureHorizons toll-ree:

x-xxx-xxx-xxxx, <8 a.m. – 8 p.m. local time, 7 days a week>.

TTY users, call 711.

Medicare membersuse our Medicare

Advantage Programs

ONE

FIVEout o



® ® ®

® ®



[ C M S C O D E ]

Plan is insured or covered by UnitedHealthcare Insurance Company or one o its afliates,a Medicare Advantage Organization with a Medicare contract.

Medicare Advantage ExplainedMedicare is health insurance or people 65 and older and others with certain disabilities. You have choices

about how you get your Medicare coverage. You can choose Original Medicare (Parts A and B) or a Medicare

Advantage plan.

Many people with Original Medicare fnd there are expenses that are not covered. To help pay or some o

these additional costs, many people choose to enroll in a Medicare Advantage plan.

• Part A helps with hospital costs

• Part B helps with doctor services

and outpatient care

Original Medicare consists of Medicare Parts A and B

• Medicare Advantage plans

cover at least the same services

as Parts A and B

Medicare Advantage (Part C) Combines Your Coverage into ONE Plan

Original Medicare

(Parts A and B)

Operated by the Federal government.

Medicare pays ees or your care

directly to the doctors and

hospitals you visit

DPART

Optional Plan

You Can Add

= +APART

BPART

Original Medicare

CPART

DPART

Operated by private companies

approved by Medicare.

Individuals must have both

Parts A and B to enroll. You pay a

low or no additional monthly plan

premium beyond the

Medicare Part B premium

= + +

Medicare Advantage plans may be a lower-cost alternative to Original Medicare. Medicare

Advantage can oer extra preventive benefts and prescription drugs all in ONE convenient plan.

Prescription

Drug Coverage

Other Services

May Be Included

• Part D (optional add-on) stand-alone prescription drug plans

can be added to help with the cost o prescription drugs

•Most preventive care services are not covered –

expect to pay additional costs or these services

• Original Medicare has unpredictable out-o-pocket expenses

• Prescription drug coverage (Part D) is included in many

Medicare Advantage plans

• Preventive care services like dental, vision, hearing and

oot care may be included at no extra charge

• Medicare Advantage plans have predictable out-o-pocket

expenses

OVEX11MP3244608_000



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To verify your provider is in the plan’s network or for additional plan information

visit us online at www.AARPMedicarePlans.com2

The 2011 UnitedHealth Passport® ProgramThe UnitedHealth Passport® Program is Included in Your Plan.

You pay no additional charge (beyond your monthly

health plan premium) or health care coverage while

you travel within the UnitedHealth Passport® service

area. Simply pay the same copay or coinsurance asyou would at home to receive non‑emergency care

benet coverage when traveling within the service

area, including preventive care, specialist care and

hospitalizations. Emergency care is covered worldwide.

The gray states on the map to the right show the

states in which there are UnitedHealth Passport®

service areas. I you are a plan member who resides

within one o the counties in this list, you are eligible

to participate in the UnitedHealth Passport Program. I you travel to any o the counties on this list, you will be

able to use the Passport benet to access routine and preventive care as needed.

Alabama

Autauga, Baldwin, Bibb, Blount, Chilton, Elmore,

Jeferson, Lowndes, Macon, Mobile, Montgomery,

Russell, Shelby, St. Clair, Walker

Arizona

Cochise, Graham, Maricopa, Pima, Pinal, Santa Cruz,

Yavapai

Arkansas

Benton, Carroll, Craword, Sebastian, Washington

Connecticut1

All Counties in the State o Connecticut

Florida

All Counties in the State o Florida

Georgia

Chatham, Cherokee, Clayton, Cobb, Columbia,

DeKalb, Forsyth, Fulton, Harris, Muscogee, Rich‑

mond

Hawaii

All Counties in the State o Hawaii

Idaho

Ada, Canyon

Illinois

Bureau, Carroll, Cook, Henderson, Henry, Jersey, Jo

Daviess, Kane, Knox, Madison, Marshall, Mercer,

Monroe, Peoria, Putnam, Rock Island, Stark, St. Clair,

Tazewell, Warren, Whiteside, Will, Woodord

Indiana

Adams, Allen, Boone, Fulton, Hamilton, Hancock,

Hendricks, Huntington, Johnson, Kosciusko, Madi‑

son, Marion, Noble, Posey, St. Joseph, Vanderburgh,Warrick, Wells, Whitley

Iowa

Appanoose, Benton, Black Hawk, Boone, Bremer,

Buchanan, Butler, Cedar, Chickasaw, Clarke, Clayton,

Clinton, Craword, Dallas, Davis, Delaware, Des

Moines, Dubuque, Fayette, Floyd, Greene, Grundy,

Guthrie, Hamilton, Hardin, Henry, Iowa, Jackson,

Jasper, Jeferson, Johnson, Jones, Keokuk, Lee, Linn,

Louisa, Lucas, Madison, Mahaska, Marion, Marshall,

Monroe, Muscatine, Page, Polk, Pottawattamie,

Poweshiek, Scott, Shelby, Story, Tama, Van Buren,

Wapello, Warren, Washington, Wayne

Kansas

Johnson, Sedgwick



Kentucky

Boone, Campbell, Kenton

Maine

Cumberland, Kennebec, Sagadahoc, York

Massachusetts

All Counties in the State o Massachusetts

MichiganAllegan, Kent, Ottawa

Missouri

Barry, Cass, Christian, Cole, Craword, Dade, Dallas,

Douglas, Franklin, Gasconade, Greene, Jackson,

Jeferson, Laclede, Laayette, Lawrence, Lincoln,

McDonald, Polk, St. Charles, St. Louis, St. Louis City,

Stone, Texas, Warren, Washington, Webster, Wright

Nebraska

Burt, Cass, Douglas, Otoe, Sarpy, Washington

New Mexico

Dona Ana, Grant, Hidalgo, Luna, Sierra

New York1

All Counties in the State o New York

North Carolina

Alamance, Caswell, Catawba, Chatham, Cumberland,

Davidson, Davie, Durham, Forsyth, Guilord, Haywood,

Henderson, Iredell, Mecklenburg, Orange, Person,

Randolph, Rockingham, Rowan, Stokes, Surry, Wake,

Wilkes, Yadkin

Ohio

Butler, Clark, Clermont, Cuyahoga, Delaware, Franklin,

Greene, Hamilton, Madison, Mahoning, Montgomery,

Preble, Stark, Summit, Trumbull, Warren

Oregon2

Clackamas, Lane, Marion, Multnomah, Washington,

Yamhill

Pennsylvania

Erie, Lancaster, Lehigh, Northampton, York

Rhode Island

All Counties in the State o Rhode Island

South Carolina

Beauort, Charleston, Greenville, York

Tennessee

Anderson, Blount, Bradley, Campbell, Carter,

Claiborne, Cocke, Davidson, DeKalb, Fayette,Grainger, Greene, Hamblen, Hamilton, Hancock,

Hawkins, Hickman, Jeferson, Johnson, Knox,

Loudon, McMinn, Meigs, Monroe, Morgan, Roane,

Rutherord, Scott, Sevier, Shelby, Sullivan, Tipton,

Unicoi, Union, Washington

Texas

Austin, Brazoria, El Paso, Fort Bend, Hardin, Harris,

Jeferson, Liberty, Montgomery

Utah

Box Elder, Cache, Davis, Morgan, Salt Lake, Summit,Tooele, Utah, Wasatch, Weber

Vermont

All Counties in the State o Vermont

Virginia

Bland, Botetourt, Bristol City, Buchanan, Chester‑

eld, Craig, Dickenson, Floyd, Franklin, Goochland,

Grayson, Lee, Hanover, Henrico, Montgomery,

Newport News City, Norolk City, Norton City, Ports‑

mouth City, Radord City, Richmond City, Roanoke,Roanoke City, Russell, Salem City, Scott, Smyth,

Tazewell, Washington, Wise, Wythe

Washington

Skagit, Spokane, Whatcom

Wisconsin

Brown, Calumet, Dodge, Fond Du Lac, Green Lake,

Kewaunee, La Crosse, Manitowoc, Milwaukee, Monroe,

Oconto, Outagamie, Ozaukee, Racine, Shawano,

Sheboygan, Trempeleau, Vernon, Washington,

Waukesha, Waupaca, Waushara, Winnebago

1 Members o HMO plans H3307 in New York as well as Point o Service plans H0752 in Connecticut and

H3107 in New Jersey may access Passport services in the state o Florida only.

2 The H3805 HMO plans in the Oregon counties o Clackamas, Lane, Marion, Multnomah and Washington do

not participate in UnitedHealth Passport. Thereore, members o these plans are not eligible to participate in

the program.

Plan is insured or covered by UnitedHealthcare Insurance Company or one o its afliates,a Medicare Advantage organization with a Medicare contract.



Plan is insured or covered by UnitedHealthcare Insurance Company or one o its aliates,a Medicare Advantage organization with a Medicare contract.

Ater Medicare approves your enrollment you will receive your Welcome Letter, New Member Kit and

your Member ID card.

Ready to Enroll?Things to Do Beore You Enroll:

I’m a Member…What’s Next?Enjoy Peace o Mind with One Convenient Plan

Review the beneft inormation in this booklet.

You may choose to contact your doctor to confrm i he or she is in the

network or you may ask your sales agent to check or you. For a complete

list o plan providers, visit our Web site.

Check the Drug List in this booklet to see i your medications are included.

Visit our Web site or a detailed listing o prescription medications. (or MAPD plans)

Have your Original Medicare ID card ready or other proo that states you are eligible or

Medicare. This inormation will help you fll out the Enrollment Form.

Customer service phone number is located

on the back o your card.

Please secure your Original Medicare card

in a sae place.

CHOICE

an informedkE

This is a sample card; your card may look diferent.

www.myRPedicare.com

Register online to view your personal inormation, plan details, coverage summaries, payment history,

options and claims.



Summary of Benefits January 1, 2011 — December 31, 2011

AARP® MedicareComplete® Plus (HMO-POS)H2182-001

Georgia: Chatham, Cherokee, Clayton, Cobb, DeKalb, Forsyth,Fulton counties

AAGA11PO3240581_000

H0755Y0066_100816EA01_SB_MAMAPD CMS Approved 09082010



Section I - Introduction to Summary of Benefits

Thank you for your interest in AARP MedicareComplete Plus (HMO-POS). Our plan is offered byUNITEDHEALTHCARE INSURANCE COMPANY/SecureHorizons by UnitedHealthcare, a Medicare AdvantageHealth Maintenance Organization (HMO), with a point-of-service option (POS). This Summary of Benefitstells you some features of our plan. It doesn't list every service that we cover or list every limitation or

exclusion. To get a complete list of our benefits, please call AARP MedicareComplete Plus (HMO-POS) andask for the "Evidence of Coverage".

You Have Choices in Your Health Care

As a Medicare beneficiary, you can choose from different Medicare options. One option is the Original(fee-for-service) Medicare Plan. Another option is a Medicare health plan, like AARP MedicareCompletePlus (HMO-POS). You may have other options too. You make the choice. No matter what you decide, youare still in the Medicare Program.

You may join or leave a plan only at certain times. Please call AARP MedicareComplete Plus (HMO-POS)at the number listed at the end of this introduction or 1-800-MEDICARE (1-800-633-4227) for moreinformation. TTY/TDD users should call 1-877-486-2048. You can call this number 24 hours a day, 7 daysa week.

How Can I Compare My Options?

You can compare AARP MedicareComplete Plus (HMO-POS) and the Original Medicare Plan using thisSummary of Benefits. The charts in this booklet list some important health benefits. For each benefit, youcan see what our plan covers and what the Original Medicare Plan covers.

Our members receive all of the benefits that the Original Medicare Plan offers. We also offer more benefits,which may change from year to year.

Where is AARP MedicareComplete Plus (HMO-POS) Available?The service area for this plan includes: Chatham, Cherokee, Clayton, Cobb, DeKalb, Forsyth, Fulton Counties,GA. You must live in one of these areas to join the plan.

Who is Eligible to Join AARP MedicareComplete Plus (HMO-POS)

You can join AARP MedicareComplete Plus (HMO-POS) if you are entitled to Medicare Part A and enrolledin Medicare Part B and live in the service area. However, individuals with End Stage Renal Disease aregenerally not eligible to enroll in AARP MedicareComplete Plus (HMO-POS) unless they are members ofour organization and have been since their dialysis began.

Can I Choose My Doctors?

AARP MedicareComplete Plus (HMO-POS) has formed a network of doctors, specialists, and hospitals.You can use any doctor who is part of our network. In some cases, you may also go to doctors outside ofour network. The health providers in our network can change at any time.

You can ask for a current Provider Directory or for an up-to-date list visit us at www.AARPMedicarePlans.com

Our customer service number is listed at the end of this introduction.



What Happens if I go to a Doctor Who's Not in Your Network?

You can go to doctors, specialists, or hospitals in or out of network. You may have to pay more for theservices you receive outside the network, and you may have to follow special rules prior to getting servicesin and/or out of network. For more information, please call the customer service number at the end ofthis introduction.

Where can I Get My Prescriptions if I Join This Plan?AARP MedicareComplete Plus (HMO-POS) has formed a network of pharmacies. You must use a networkpharmacy to receive plan benefits. We may not pay for your prescriptions if you use an out-of-networkpharmacy, except in certain cases. The pharmacies in our network can change at any time. You can askfor a pharmacy directory or visit us at www.AARPMedicarePlans.com Our customer service number islisted at the end of this introduction.

AARP MedicareComplete Plus (HMO-POS) has a list of preferred pharmacies. At these pharmacies, youmay get your drugs at a lower co-pay or co-insurance. You may go to a non-preferred pharmacy, but youmay have to pay more for your prescription drugs.

Does My Plan Cover Medicare Part B or Part D Drugs?AARP MedicareComplete Plus (HMO-POS) does cover both Medicare Part B prescription drugs and MedicarePart D prescription drugs.

What is a Prescription Drug Formulary?

AARP MedicareComplete Plus (HMO-POS) uses a formulary. A formulary is a list of drugs covered by yourplan to meet patient needs. We may periodically add, remove, or make changes to coverage limitationson certain drugs or change how much you pay for a drug. If we make any formulary change that limits ourmembers' ability to fill their prescriptions, we will notify the affected enrollees before the change is made.We will send a formulary to you and you can see our complete formulary on our Web site at

www.AARPMedicarePlans.comIf you are currently taking a drug that is not on our formulary or subject to additional requirements orlimits, you may be able to get a temporary supply of the drug. You can contact us to request an exceptionor switch to an alternative drug listed on our formulary with your physician's help. Call us to see if you canget a temporary supply of the drug or for more details about our drug transition policy.

How Can I Get Extra Help With My Prescription Drug Plan Costs or Get Extra HelpWith Other Medicare Costs?

You may be able to get extra help to pay for your prescription drug premiums and costs as well as get helpwith other Medicare costs. To see if you qualify for getting extra help, call:

* 1-800-MEDICARE (1-800-633-4227). TTY/TDD users should call 1-877-486-2048, 24 hours a day/7days a week and see www.medicare.gov 'Programs for People with Limited Income and Resources' in thepublication Medicare & You.

* The Social Security Administration at 1-800-772-1213 between 7 a.m. and 7 p.m., Monday throughFriday. TTY/TDD users should call 1-800-325-0778 or

* Your State Medicaid Office.



What Are My Protections in This Plan?

All Medicare Advantage Plans agree to stay in the program for a full year at a time. Each year, the plansdecide whether to continue for another year. Even if a Medicare Advantage Plan leaves the program, youwill not lose Medicare coverage. If a plan decides not to continue, it must send you a letter at least 90days before your coverage will end. The letter will explain your options for Medicare coverage in your area.

As a member of AARP MedicareComplete Plus (HMO-POS), you have the right to request an organization

determination, which includes the right to file an appeal if we deny coverage for an item or service, andthe right to file a grievance. You have the right to request an organization determination if you want us toprovide or pay for an item or service that you believe should be covered. If we deny coverage for yourrequested item or service, you have the right to appeal and ask us to review our decision. You may ask usfor an expedited (fast) coverage determination or appeal if you believe that waiting for a decision couldseriously put your life or health at risk, or affect your ability to regain maximum function. If your doctormakes or supports the expedited request, we must expedite our decision. Finally, you have the right tofile a grievance with us if you have any type of problem with us or one of our network providers that doesnot involve coverage for an item or service. If your problem involves quality of care, you also have the rightto file a grievance with the Quality Improvement Organization (QIO) for your state. Please refer to theEvidence of Coverage (EOC) for the QIO contact information.

As a member of AARP MedicareComplete Plus (HMO-POS), you have the right to request a coveragedetermination, which includes the right to request an exception, the right to file an appeal if we denycoverage for a prescription drug, and the right to file a grievance. You have the right to request a coveragedetermination if you want us to cover a Part D drug that you believe should be covered. An exception is atype of coverage determination. You may ask us for an exception if you believe you need a drug that isnot on our list of covered drugs or believe you should get a non-preferred drug at a lower out-of-pocketcost. You can also ask for an exception to cost utilization rules, such as a limit on the quantity of a drug.If you think you need an exception, you should contact us before you try to fill your prescription at apharmacy. Your doctor must provide a statement to support your exception request. If we deny coveragefor your prescription drug(s), you have the right to appeal and ask us to review our decision. Finally, you

have the right to file a grievance if you have any type of problem with us or one of our network pharmaciesthat does not involve coverage for a prescription drug. If your problem involves quality of care, you alsohave the right to file a grievance with the Quality Improvement Organization (QIO) for your state. Pleaserefer to the Evidence of Coverage (EOC) for the QIO contact information.

What is a Medication Therapy Management (MTM) Program?

A Medication Therapy Management (MTM) Program is a free service we offer. You may be invited toparticipate in a program designed for your specific health and pharmacy needs. You may decide not toparticipate but it is recommended that you take full advantage of this covered service if you are selected.Contact AARP MedicareComplete Plus (HMO-POS) for more details.

What Types of Drugs May be Covered Under Medicare Part B?

Some outpatient prescription drugs may be covered under Medicare Part B. These may include, but arenot limited to, the following types of drugs. Contact AARP MedicareComplete Plus (HMO-POS) for moredetails.

Some Antigens: If they are prepared by a doctor and administered by a properly instructed person (whocould be the patient) under doctor supervision.Osteoporosis Drugs: Injectable drugs for osteoporosis for certain women with Medicare.



Erythropoietin (Epoetin Alfa or Epogen®): By injection if you have end-stage renal disease (permanent

kidney failure requiring either dialysis or transplantation) and need this drug to treat anemia.Hemophilia Clotting Factors: Self-administered clotting factors if you have hemophilia.Injectable Drugs: Most injectable drugs administered incident to a physician's service.Immunosuppressive Drugs: Immunosuppressive drug therapy for transplant patients if the transplantwas paid for by Medicare, or paid by a private insurance that paid as a primary payer to your Medicare

Part A coverage, in a Medicare-certified facility.Some Oral Cancer Drugs: If the same drug is available in injectable form.Oral Anti-Nausea Drugs: If you are part of an anti-cancer chemotherapeutic regimen.Inhalation and Infusion Drugs provided through DME.

Where Can I Find Information on Plan Ratings?

The Medicare program rates how well plans perform in different categories (for example, detecting andpreventing illness, ratings from patients and customer service). If you have access to the web, you mayuse the web tools on www.medicare.gov and select "Compare Medicare Prescription Drug Plans" or"Compare Health Plans and Medigap Policies in Your Area" to compare the plan ratings for Medicare plansin your area. You can also call us directly to obtain a copy of the plan ratings for this plan. Our customer

service number is listed below.

Please call SecureHorizons by UnitedHealthcare for more information about

AARP MedicareComplete Plus (HMO-POS).

Visit us at www.AARPMedicarePlans.comor, call us:

Customer Service Hours:

Sunday, Monday, Tuesday, Wednesday, Thursday, Friday, Saturday, 8:00 a.m - 8:00 p.m Eastern

Current members should call toll-free 1-800-643-4845 for questions related to the

Medicare Advantage Program and Medicare Part D Prescription Drug program.

TTY/TDD: 711

Prospective members should call toll-free 1-800-547-5514 for questions related to the

Medicare Advantage and Medicare Part D Prescription Drug Program.

TTY/TDD: 711

For more information about Medicare, please call Medicare at 1-800-MEDICARE

(1-800-633-4227). TTY users should call 1-877-486-2048. You can call 24 hours a day, 7 days

a week. Or, visit www.medicare.gov on the web.

This document may be available in a different format or language. For additional information, call

customer service at the phone number listed above.

Este documento puede estar disponible en diferentes formatos e idiomas. Por favor, llame al número

de Servicio al Cliente dado anteriormente si necesita obtener más información.

本資訊可以不同形式或語言提供。如需更多資訊，請撥打上文所列的電話號碼，與客戶服

務部聯絡。

If you have special needs, this document may be available in other formats.



Section II - Summary Of Benefits

If you have any questions about this plan's benefits or costs, please contact SecureHorizons by UnitedHealthcarefor details.

AARP MedicareComplete Plus(HMO-POS)

Original MedicareBenefit

Important Information

General

$0 monthly plan premium in additionto your monthly Medicare Part Bpremium.

In 2010 the monthly Part B Premiumwas $96.40 and may change for 2011and the yearly Part B deductibleamount was $155 and may change for2011.

Premium and Other

Important

Information

Most people will pay the standardmonthly Part B premium in addition toIf a doctor or supplier does not accept

assignment, their costs are oftenhigher, which means you pay more.

their MA plan premium. However,some people will pay higher Part B and

Part D premiums because of theirMost people will pay the standardmonthly Part B premium. However,

yearly income (over $85,000 forsingles, $170,000 for married

some people will pay a higher premiumcouples). For more information about

because of their yearly income (overPart B and Part D premiums based on

$85,000 for singles, $170,000 forincome, call Medicare at

married couples). For more information1-800-MEDICARE (1-800-633-4227).

about Part B premiums based onTTY users should call 1-877-486-2048.

income, call Medicare atYou may also call Social Security at

1-800-MEDICARE (1-800-633-4227).1-800-772-1213. TTY users should call1-800-325-0778.

TTY users should call 1-877-486-2048.You may also call Social Security at1-800-772-1213. TTY users should call1-800-325-0778.

This plan covers all Medicare-coveredpreventive services with zero costsharing.

In-Network

$3,380 out-of-pocket limit.

This limit includes onlyMedicare-covered services.

In-Network

No referral required for networkdoctors, specialists, and hospitals.

You may go to any doctor, specialist

or hospital that accepts Medicare.

Doctor and Hospital

Choice(For moreinformation, seeEmergency Care -#15 and UrgentlyNeeded Care - #16.)

Out of Service Area

Plan covers you when you travel in theU.S.

Inpatient Care





Inpatient Care (continued)

In-Network

No limit to the number of days covered

by the plan each benefit period.

In 2010 the amounts for each benefitperiod were:

Inpatient Hospital

Care

(includes SubstanceAbuse andRehabilitationServices)

Days 1 - 60: $1100 deductible

For Medicare-covered hospital stays:Days 61 - 90: $275 per dayDays 91 - 150: $550 per lifetimereserve day These amounts willchange for 2011. Call1-800-MEDICARE (1-800-633-4227)for information about lifetime reservedays.

Days 1 - 7: $295 copay per dayDays 8 - 90: $0 copay per day

$0 copay for each additional hospitalday.

Lifetime reserve days can only be usedonce.

A "benefit period" starts the day you

go into a hospital or skilled nursingfacility. It ends when you go for 60days in a row without hospital orskilled nursing care. If you go into thehospital after one benefit period hasended, a new benefit period begins.You must pay the inpatient hospitaldeductible for each benefit period.There is no limit to the number ofbenefit periods you can have.

In-Network

You get up to 190 days in a PsychiatricHospital in a lifetime.

Same deductible and copay asinpatient hospital care (see "InpatientHospital Care" above).

Inpatient Mental

Health Care

For Medicare-covered hospital stays:190 day lifetime limit in a PsychiatricHospital. Days 1 - 7: $295 copay per day

Days 8 - 90: $0 copay per day

In-Network

Plan covers up to 100 days eachbenefit period

In 2010 the amounts for each benefitperiod after at least a 3-day coveredhospital stay were:

Skilled Nursing

Facility (SNF)(in a

Medicare-certifiedskilled nursingfacility)

No prior hospital stay is required.

For Medicare-covered SNF stays:

Days 1 - 20: $0 per dayDays 21 - 100: $137.50 per dayThese amounts will change for 2011.

Days 1 - 34: $100 copay per day100 days for each benefit period.Days 35 - 100: $0 copay per day

A "benefit period" starts the day yougo into a hospital or SNF. It ends whenyou go for 60 days in a row withouthospital or skilled nursing care. If you





Inpatient Care (continued)

go into the hospital after one benefitperiod has ended, a new benefit period

begins. You must pay the inpatienthospital deductible for each benefitperiod. There is no limit to the numberof benefit periods you can have.

In-Network

$0 copay for each Medicare-coveredhome health visit.

$0 copay.Home Health Care

(includes medicallynecessaryintermittent skillednursing care, homehealth aide services,

and rehabilitationservices, etc.)

General

You must get care from aMedicare-certified hospice.

You pay part of the cost for outpatientdrugs and inpatient respite care.

You must get care from aMedicare-certified hospice.

Hospice

Outpatient Care

In-Network

$10 copay for each primary caredoctor visit for Medicare-coveredbenefits.

20% coinsuranceDoctor Office Visits

$30 copay for each in-area, networkurgent care Medicare-covered visit.

$35 copay for each specialist visit forMedicare-covered benefits.

In-Network

50% of the cost for eachMedicare-covered visit.

Routine care not covered

20% coinsurance for manualmanipulation of the spine to correct

Chiropractic

Services

subluxation (a displacement or Medicare-covered chiropractic visitsare for manual manipulation of themisalignment of a joint or body part)spine to correct subluxation (aif you get it from a chiropractor or

other qualified providers. displacement or misalignment of a joint or body part) if you get it from achiropractor or other qualifiedproviders.





Outpatient Care (continued)

In-Network

$35 copay for each Medicare-covered

visit.

Routine care not covered.

20% coinsurance for medicallynecessary foot care, including care for

Podiatry Services

medical conditions affecting the lowerlimbs.

$35 copay for up to 6 routine visit(s)every year

Medicare-covered podiatry benefitsare for medically-necessary foot care.

In-Network

$40 copay for each Medicare-coveredindividual therapy visit.

45% coinsurance for most outpatientmental health services.

Outpatient Mental

Health Care

$30 copay for each Medicare-coveredgroup therapy visit.

In-Network

$40 copay for Medicare-coveredindividual visits.

20% coinsuranceOutpatient

Substance Abuse

Care

$30 copay for Medicare-covered groupvisits.

In-Network

20% of the cost for eachMedicare-covered ambulatory surgicalcenter visit.

20% coinsurance for the doctor

Specified copayment for outpatienthospital facility charges. Copay cannotexceed than Part A inpatient hospitaldeductible.

Outpatient

Services/Surgery

20% of the cost for eachMedicare-covered outpatient hospitalfacility visit.

20% coinsurance for ambulatorysurgical center facility charges

In-Network

$200 copay for Medicare-coveredambulance benefits.

20% coinsuranceAmbulance

Services(medically necessaryambulance services)

General

$50 copay for Medicare-coveredemergency room visits.

20% coinsurance for the doctor

Specified copayment for outpatienthospital emergency room (ER) facilitycharge.

Emergency Care(You may go to anyemergency room ifyou reasonablybelieve you needemergency care.)

Worldwide coverage.

If you are admitted to the hospitalwithin 24-hour(s) for the same

ER Copay cannot exceed Part Ainpatient hospital deductible.





Outpatient Care (continued)

condition, you pay $0 for theemergency room visit

You don't have to pay the emergencyroom copay if you are admitted to the

hospital for the same condition within3 days of the emergency room visit.

NOT covered outside the U.S. exceptunder limited circumstances.

General

$40 copay for Medicare-coveredurgently needed care visits.

20% coinsurance, or a set copay

NOT covered outside the U.S. exceptunder limited circumstances.

Urgently Needed

Care(This is NOTemergency care, andin most cases, is out

of the service area.)

In-Network

$35 copay for Medicare-coveredOccupational Therapy visits.

20% coinsuranceOutpatient

Rehabilitation

Services(OccupationalTherapy, PhysicalTherapy, Speech andLanguage Therapy,Respiratory TherapyServices, Social/

PsychologicalServices, and more)

$35 copay for Medicare-coveredPhysical and/or Speech and LanguageTherapy visits.

$35 copay for Medicare-coveredCardiac Rehab services.

Outpatient Medical Services and Supplies

In-Network

20% of the cost for Medicare-covereditems.

20% coinsuranceDurable Medical

Equipment(includeswheelchairs, oxygen,etc.)

In-Network20% of the cost for Medicare-covereditems.

20% coinsuranceProsthetic Devices(includes braces,artificial limbs andeyes, etc.)





Outpatient Medical Services and Supplies (continued)

In-Network

$0 copay for Diabetes self-monitoring

training.

20% coinsurance

Nutrition therapy is for people whohave diabetes or kidney disease (but

Diabetes

Self-Monitoring

Training, NutritionTherapy, and

Supplies(includes coveragefor glucose monitors,test strips, lancets,screening tests,self-managementtraining, retinalexam/glaucoma test,and foot exam/

therapeutic softshoes)

$0 copay for Nutrition Therapy forDiabetes.

$0 copay for Diabetes supplies.

aren't on dialysis or haven't had akidney transplant) when referred by adoctor. These services can be given bya registered dietitian or include anutritional assessment and counselingto help you manage your diabetes orkidney disease.

In-Network

$0 to $10 copay for Medicare-coveredlab services.

20% coinsurance for diagnostic testsand x-rays

$0 copay for Medicare-covered labservices

Diagnostic Tests,

X-Rays, Lab

Services, and

Radiology Services0% to 20% of the cost forMedicare-covered diagnosticprocedures and tests.

Lab Services: Medicare coversmedically necessary diagnostic labservices that are ordered by your $16 copay for Medicare-covered

X-rays.treating doctor when they are providedby a Clinical Laboratory Improvement

20% of the cost for Medicare-covereddiagnostic radiology services (notincluding x-rays).

Amendments (CLIA) certifiedlaboratory that participates inMedicare. Diagnostic lab services are

20% of the cost for Medicare-coveredtherapeutic radiology services.

done to help your doctor diagnose orrule out a suspected illness orcondition. Medicare does not covermost routine screening tests, likechecking your cholesterol.

Preventive Services

In-Network

$0 copay for Medicare-covered bonemass measurement.

No coinsurance, copayment ordeductible.

Covered once every 24 months (moreoften if medically necessary) if youmeet certain medical conditions.

Bone Mass

Measurement(for people withMedicare who are atrisk)





Preventive Services (continued)

In-Network

$0 copay for Medicare-covered

colorectal screenings.

No coinsurance, copayment ordeductible for screening colonoscopy

or screening flexible sigmoidoscopy.

Colorectal

Screening Exams

(for people withMedicare age 50 andolder)

$0 copay up to 1 additionalscreening(s) every year.

Covered when you are high risk orwhen you are age 50 and older.

In-Network

$0 copay for Flu and Pneumoniavaccines.

$0 copay for Flu, and Pneumonia andHepatitis B vaccines.

You may only need the Pneumoniavaccine once in your lifetime. Call yourdoctor for more information.

Immunizations

(Flu vaccine,Hepatitis B vaccine -for people withMedicare who are atrisk, Pneumonia

vaccine)

No referral needed for Flu andpneumonia vaccines.

$0 copay for Hepatitis B vaccine.

In-Network

$0 copay for Medicare-coveredscreening mammograms.

No coinsurance, copayment ordeductible.

No referral needed.

Mammograms

(Annual Screening)(for women withMedicare age 40 andolder) Covered once a year for all women

with Medicare age 40 and older. Onebaseline mammogram covered forwomen with Medicare between age 35and 39.

In-Network

$0 copay for Medicare-covered papsmears and pelvic exams

No coinsurance, copayment, ordeductible for Pap smears.

No coinsurance, copayment, ordeductible for Pelvic and clinical breastexams.

Pap Smears and

Pelvic Exams(for women withMedicare)

$0 copay up to 1 additional papsmear(s) and pelvic exam(s) every year

Covered once every 2 years. Coveredonce a year for women with Medicareat high risk.

In-Network$0 copay for Medicare-coveredprostate cancer screening.

20% coinsurance for the digital rectalexam.

$0 for the PSA test; 20% coinsurancefor other related services.

Prostate CancerScreening Exams

(for men withMedicare age 50 andolder)

Covered once a year for all men withMedicare over age 50.






In-Network

20% of the cost for renal dialysis20% coinsurance for renal dialysis

20% coinsurance for Nutrition Therapyfor End-Stage Renal Disease

End-Stage Renal

Disease

$0 copay for Nutrition Therapy forEnd-Stage Renal Disease.

Nutrition therapy is for people whohave diabetes or kidney disease (butaren't on dialysis or haven't had akidney transplant) when referred by adoctor. These services can be given bya registered dietitian or include anutritional assessment and counselingto help you manage your diabetes orkidney disease.

Drugs covered under Medicare PartB General

20% of the cost for Part B-coveredchemotherapy drugs and other PartB-covered drugs.

Most drugs are not covered underOriginal Medicare. You can addprescription drug coverage to OriginalMedicare by joining a MedicarePrescription Drug Plan, or you can get

Prescription Drugs

all your Medicare coverage, including Drugs covered under Medicare PartD General

This plan uses a formulary. The planwill send you the formulary. You can

prescription drug coverage, by joininga Medicare Advantage Plan or aMedicare Cost Plan that offersprescription drug coverage.

also see the formulary atwww.AARPMedicarePlans.com on theweb.

Different out-of-pocket costs mayapply for people who

have limited incomes,live in long term care facilities, orhave access to Indian/Tribal/Urban(Indian Health Service).

The plan offers national in-networkprescription coverage (i.e., this wouldinclude 50 states and DC). This meansthat you will pay the same cost-sharingamount for your prescription drugs ifyou get them at an in-networkpharmacy outside of the plan's servicearea (for instance when you travel).






Total yearly drug costs are the totaldrug costs paid by both you and the

plan.The plan may require you to first tryone drug to treat your condition beforeit will cover another drug for thatcondition.

Some drugs have quantity limits.

Your provider must get priorauthorization from AARPMedicareComplete Plus (HMO-POS)for certain drugs.

You must go to certain pharmacies fora very limited number of drugs, due tospecial handling, provider coordination,or patient education requirements thatcannot be met by most pharmacies inyour network. These drugs are listedon the plan's website, formulary,printed materials, as well as on theMedicare Prescription Drug Plan Finderon Medicare.gov.

If the actual cost of a drug is less thanthe normal cost-sharing amount forthat drug, you will pay the actual cost,not the higher cost-sharing amount.

If you request a formulary exceptionfor a drug and AARPMedicareComplete Plus (HMO-POS)approves the exception, you will payTier 3: Non-Preferred Generic andNon-Preferred Brand Drugs cost

sharing for that drug.

$0 deductible.In-Network

You pay the following until total yearlydrug costs reach $2,840:

Initial Coverage

Tier 1: Preferred Generic DrugsRetail Pharmacy






$5 copay for a one-month (31-day)supply of drugs in this tier

$15 copay for a three-month (90-day)supply of drugs in this tier

Tier 2: Generic and Preferred BrandDrugs

$45 copay for a one-month (31-day)supply of drugs in this tier$135 copay for a three-month(90-day) supply of drugs in this tier

Tier 3: Non-Preferred Generic andNon-Preferred Brand Drugs

$85 copay for a one-month (31-day)supply of drugs in this tier$255 copay for a three-month(90-day) supply of drugs in this tier

Tier 4: Specialty Tier Drugs

33% coinsurance for a one-month(31-day) supply of drugs in this tier33% coinsurance for a three-month(90-day) supply of drugs in this tier

Tier 1: Preferred Generic DrugsLong Term Care

Pharmacy$5 copay for a one-month (31-day)supply of drugs in this tier






33% coinsurance for a one-month(31-day) supply of drugs in this tier

Tier 1: Preferred Generic DrugsMail Order

$10 copay for a three-month (90-day)supply of drugs in this tier from apreferred mail order pharmacy.






$15 copay for a three-month (90-day)supply of drugs in this tier from a

non-preferred mail order pharmacy.Tier 2: Generic and Preferred BrandDrugs

$125 copay for a three-month(90-day) supply of drugs in this tierfrom a preferred mail orderpharmacy.$135 copay for a three-month(90-day) supply of drugs in this tierfrom a non-preferred mail orderpharmacy.


$245 copay for a three-month(90-day) supply of drugs in this tierfrom a preferred mail orderpharmacy.$255 copay for a three-month(90-day) supply of drugs in this tierfrom a non-preferred mail orderpharmacy.


33% coinsurance for a three-month(90-day) supply of drugs in this tierfrom a preferred mail orderpharmacy.33% coinsurance for a three-month(90-day) supply of drugs in this tierfrom a non-preferred mail orderpharmacy.

After your total yearly drug costs reach$2,840, you receive a discount on

Coverage Gap

brand name drugs and pay 93% of the

plan's costs for all generic drugs, untilyour yearly out-of-pocket drug costsreach $4,550.

After your yearly out-of-pocket drugcosts reach $ 4,550, you pay thegreater of:

Catastrophic Coverage






A $ 2.50 copay for generic (includingbrand drugs treated as generic) and

a $ 6.30 copay for all other drugs, or5% coinsurance.

Plan drugs may be covered in specialcircumstances, for instance, illness

Out-of-Network

while traveling outside of the plan'sservice area where there is no networkpharmacy. You may have to pay morethan your normal cost-sharing amountif you get your drugs at anout-of-network pharmacy. In addition,

you will likely have to pay thepharmacy's full charge for the drug andsubmit documentation to receivereimbursement from AARPMedicareComplete Plus (HMO-POS).

You will be reimbursed up to the fullcost of the drug minus the following

Out-of-Network Initial

Coverage

for drugs purchased out-of-networkuntil total yearly drug costs reach$2,840:

Tier 1: Preferred Generic Drugs







33% coinsurance for a one-month(31-day) supply of drugs in this tier

You will not be reimbursed for thedifference between the Out-of-Network






Pharmacy charge and the plan'sIn-Network allowable amount.

You will be reimbursed up to 7% of theplan allowable cost for generic drugs

Out-of-Network

Coverage Gap

purchased out-of-network until totalyearly out-of-pocket drug costs reach$4,550.

You will be reimbursed up to thediscounted price for brand name drugspurchased out-of-network until totalyearly out-of-pocket drug costs reach

$4,550.You will not be reimbursed for thedifference between the Out-of-NetworkPharmacy charge and the plan'sIn-Network allowable amount.

After your yearly out-of-pocket drugcosts reach $ 4,550, you will be

Out-of-Network

Catastrophic Coverage

reimbursed for drugs purchasedout-of-network up to the full cost ofthe drug minus your cost share, which

is the greater of:

A $ 2.50 copay for generic (includingbrand drugs treated as generic) anda $ 6.30 copay for all other drugs, or5% coinsurance.

You will not be reimbursed for thedifference between the Out-of-NetworkPharmacy charge and the plan'sIn-Network allowable amount.

In-NetworkIn general, preventive dental benefits(such as cleaning) not covered.

Preventive dental services (such ascleaning) not covered.

Dental Services

$35 copay for Medicare-covered dentalbenefits.

In-NetworkRoutine hearing exams and hearingaids not covered.

Hearing Services$35 copay for Medicare-covereddiagnostic hearing exams






20% coinsurance for diagnostic hearingexams.

$0 to $35 copay for up to 1 routinehearing test(s) every year

$0 copay per hearing aid$300 plan coverage limit for hearingaids every two years.

In-Network20% coinsurance for diagnosis andtreatment of diseases and conditionsof the eye.

Vision Services$0 copay for one pair of eyeglassesor contact lenses after cataractsurgery.

Routine eye exams and glasses notcovered.

$0 to $35 copay for exams todiagnose and treat diseases andconditions of the eye.

Medicare pays for one pair of

eyeglasses or contact lenses aftercataract surgery.

$35 copay for up to 1 routine eye

exam(s) every year$30 copay for contacts$0 copay for up to 1 pair(s) of lensesevery two yearsAnnual glaucoma screenings covered

for people at risk. $30 copay for up to 1 frame(s) everytwo years

$105 plan coverage limit for contactlenses every two years.

$70 plan coverage limit for eye glassframes every two years.

In-Network

$0 copay for the requiredMedicare-covered initial preventive

When you join Medicare Part B, thenyou are eligible as follows.

During the first 12 months of your newPart B coverage, you can get either a

Welcome to

Medicare; and

Annual Wellness

Visit physical exam and annual wellnessvisits.

Welcome to Medicare exam or anAnnual Wellness visit.

After your first 12 months, you can getone Annual Wellness visit every 12months.

There is no coinsurance, copaymentor deductible for either the Welcometo Medicare exam or the AnnualWellness visit.

The Welcome to Medicare exam doesnot include lab tests.






In-Network

The plan covers the following health/

wellness education benefits:

Smoking Cessation: Covered if orderedby your doctor. Includes two

counseling attempts within a 12-month

Health/Wellness

Education

period if you are diagnosed with a Written health education materials,including Newsletterssmoking-related illness or are taking

medicine that may be affected by Nursing Hotlinetobacco. Each counseling attempt

$0 copay for each Medicare-coveredsmoking cessation counseling session.

includes up to four face-to-face visits.You pay coinsurance, and Part Bdeductible applies. $0 copay for each Medicare-covered

HIV screening.$0 copay for the HIV screening, butyou generally pay 20% of the HIV screening is covered for people

with Medicare who are pregnant andMedicare-approved amount for the people at increased risk for thedoctor's visit. HIV screening is covered

infection, including anyone who asksfor people with Medicare who arefor the test. Medicare covers this testpregnant and people at increased riskonce every 12 months or up to threetimes during a pregnancy.

for the infection, including anyone whoasks for the test. Medicare covers thistest once every 12 months or up tothree times during a pregnancy.

In-Network

This plan does not cover routine

transportation.

Not covered.Transportation

(Routine)

In-Network

This plan does not cover Acupuncture.Not covered.Acupuncture

Out-of-Network

Point of Service coverage is availablefor the following benefits:

You may go to any doctor, specialistor hospital that accepts Medicare.

Point of Service

- Inpatient Hospital Acute

Inpatient Hospital Psychiatric

Skilled Nursing Facility (SNF)Comprehensive OutpatientRehabilitation Facility (CORF)Partial HospitalizationHome Health ServicesPrimary Care Physician ServicesChiropractic ServicesOccupational Therapy ServicesPhysician Specialist ServicesMental Health Specialty Services






Podiatry ServicesOther Health Care Professional

Psychiatric ServicesPhysical Therapy and Speech/Language Pathology ServicesOutpatient Diag Procs/Tests/LabServicesDiagnostic Radiological ServicesTherapeutic Radiological ServicesOutpatient X-RaysOutpatient Hospital ServicesAmbulatory Surgical Center (ASC)ServicesOutpatient Substance AbuseCardiac Rehabilitation Services

Ambulance ServicesDMEProsthetics/Medical SuppliesDiabetes Monitoring SuppliesBloodHealth Education/WellnessImmunizationsRoutine Physical ExamsPap Smears and Pelvic ExamsProstate ScreeningColorectal ScreeningBone Mass MeasurementMammography Screening

Diabetes MonitoringNutrition Therapy for Diabetes andRenal DiseaseComprehensive DentalEye ExamsEye WearHearing Exams

$325 copay per hospital day.

For Inpatient Psychiatric Hospitalstays:

Days 1 - 90: $325 copay per day

For each SNF stay:

Days 1 - 40: $175 copay per SNF dayDays 41 - 100: $0 copay per SNF day

$15 copay for

Primary Care Physician ServicesOther Health Care ProfessionalRoutine Physical Exams






$40 copay for

Comprehensive Outpatient

Rehabilitation Facility (CORF)Occupational Therapy ServicesPhysician Specialist ServicesPodiatry ServicesPhysical Therapy and Speech/Language Pathology ServicesCardiac Rehabilitation ServicesComprehensive DentalEye ExamsHearing Exams

30% of the cost for

Home Health ServicesDiagnostic Radiological ServicesTherapeutic Radiological ServicesOutpatient Hospital ServicesAmbulatory Surgical Center (ASC)ServicesDMEProsthetics/Medical SuppliesDiabetes Monitoring SuppliesPap Smears and Pelvic ExamsProstate ScreeningColorectal ScreeningBone Mass Measurement

Mammography ScreeningDiabetes MonitoringNutrition Therapy for Diabetes andRenal DiseaseEye Wear

$10 copay or 30% of the cost for

Outpatient Diag Procs/Tests/LabServices

$21 copay for

Outpatient X-Rays

$75 copay for

Partial Hospitalization

$200 copay for

Ambulance Services

$35 to $45 copay for

Mental Health Specialty ServicesPsychiatric Services






Outpatient Substance Abuse

$0 copay for

BloodHealth Education/WellnessImmunizations

50% of the cost for

Chiropractic Services

Optional Supplemental Package #1

General

Package: 1 - Dental Platinum Rider:

Premium and Other


$32 monthly premium, in addition toyour $0 monthly plan premium and themonthly Medicare Part B premium, forthe following optional benefits:

Preventive DentalComprehensive Dental

General

Plan offers additional comprehensivedental benefits.

Dental Services

In-Network$0 copay for up to 1 cleaning(s)every six months$0 copay for up to 1 fluoridetreatment(s) every six months$0 copay for up to 1 oral exam(s)every six months$0 copay for up to 1 dental x-ray(s)

$1,000 plan coverage limit for dentalbenefits every year.

Optional Supplemental Package #2

General

Package: 2 - Fitness Rider:

Premium and Other


$13 monthly premium, in addition toyour $0 monthly plan premium and themonthly Medicare Part B premium, forthe following optional benefits:

Health Education/Wellness



Additional Information



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Member Appeals and Grievances ProcessMembers o our Medicare Advantage health plans have the right to request an organization determination

including the right to fle an appeal and the right to fle a grievance. Medicare Advantage health plan

organizations must identiy, track, resolve and report all activity related to an appeal or grievance.

Medicare Advantage Member AppealsWhat is an Appeal?An appeal is a type o request you make when you want us to reconsider a decision concerning coverage o

a service or the amount your health plan pays or will pay or a service. The initial decision concerning medical

care or services is called an “organization determination.”

When can an Appeal be fled?You may le an appeal within 60 calendar days o the date o the initial organization determination. The

60-day limit may be extended or good cause. Include in your written request the reason why you could

not le within the 60-day timerame.

Who can fle an Appeal?You may le an appeal or someone else may le an appeal on your behal. You must appoint the individual

to act as your representative to le the appeal or you. To learn how to name a representative, contact

Customer Service.

How can an Appeal be fled?An appeal must be led in writing directly to us. You may call Customer Service or additional inormation.

To learn how to le an appeal, contact Customer Service.

Fast ReviewsYou have the right to request and receive ast decisions afecting your medical treatment in “time-sensitive”

situations. A situation is time-sensitive i waiting or a decision to be made within the standard timeramecould seriously harm your health or your ability to unction. I your doctor provides a written or oral statement

supporting your need o a ast review we will automatically give you a ast review. A decision will be issued as

quickly as possible but no later than 72 hours ater receiving the request.

Medicare Advantage Member Grievances

What is a Grievance?A grievance is a complaint that doesn’t involve coverage or an item or service by your health plan or a

contracting medical provider. I your grievance involves quality o care, you have the right to le a grievance

with the Quality Improvement Organization (QIO) o your state. Reer to Section I o the Summary o Benets

or the name o the QIO in your state.

When can a Grievance be fled?You may le a grievance within 60 calendar days o the date o the event causing the grievance. The 60-day

limit may be extended or good cause. Include in your written request the reason why you could not le within

the 60-day timerame. There is no time limit or complaints concerning quality o care.

Who can fle a Grievance?You may le a grievance or someone else may le a grievance on your behal. You must appoint the individual

to act as your representative to le the grievance or you. To learn how to name a representative, contact

Customer Service.

1



Plan is insured or covered by UnitedHealthcare Insurance Company or one o its afliates,a Medicare Advantage organization with a Medicare contract.

How can a Grievance be fled?A grievance or Quality o Care may be led verbally by contacting Customer Service. All other grievances

must be submitted in writing.

Fast GrievancesYou have the right to le a ast grievance. We will respond to ast grievances within 24 hours o receipt.

You may le a ast grievance i you disagree with our decision to deny your request or a ast review. You

may also le a ast grievance i we notiy you that we are extending our timerame to make an organizationdetermination or reconsideration decision, or i we downgrade your expedited appeal request to standard due

to not meeting expedited criteria.

For Members with Medicare Part D Drug Coverage through our Plan

Coverage DeterminationsWe will make an initial decision as to whether or not we will provide the Part D drug you are requesting or pay

or the Part D drug you already received. This initial decision is called a “coverage determination.”

Exceptions

You or your doctor may ask us to make an exception to our Part D coverage determination. You may requestan exception i you believe you need a drug that is not on our list o covered drugs or believe you should get a

non-preerred drug at a lower out-o-pocket cost. Generally, we will only approve your request or an exception

i the alternative Part D drug is included in your plan’s ormulary or the Part D drug in the preerred tier would

not be as efective in treating your condition and/or would cause you to have adverse medical efects. Your

doctor or other prescriber must submit a statement supporting your exception request. In order to help us

make a decision more quickly, the supporting medical inormation rom your doctor or other prescriber should

be sent to us with the exception request. I we approve your exception request or a Part D non-ormulary

drug, you can’t request an exception to the copayment or coinsurance amount we require you to pay or the

drug. I you think you need an exception, you should contact us beore you try to ll your prescription at a

pharmacy.

Part D Drug AppealsI you are getting Medicare prescription Part D drug coverage through our plan you have the right to le an

appeal. This includes the right to appeal our decision regarding your exception request. Follow the process

outlined above to le an appeal. An appeal concerning coverage determinations must be led in writing

directly to us.

Part D Drug GrievancesI you are getting Medicare prescription Part D drug coverage through our plan, you have the right to le a

grievance. Follow the process outlined above to le a grievance concerning your Part D prescription drug

coverage.



SecureHorizons by UnitedHealthcare - H2182

Medicare Health Plan Ratings

The Medicare Program rates how well Medicare Advantage perorms in diferent categories (or example,

detecting and preventing illness, rating rom patients, patient saety and customer service). The inormation

provided below is a summary rating o our plan’s overall perormance. This inormation is available to help you

make the best choice. I you would like to get additional inormation on our plan’s perormance please contact

us at 1-800-547-5514 (toll-ree) or 711 (TTY/TDD) or prospective members, 1-800-643-4845 (toll-ree) or

711 (TTY/TDD) or current members or you may visit www.medicare.gov.

Below is a summary o how our plan rated in quality and perormance.

The number of stars show how well our plans perform. means excellent means very good means good means air means poor

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Summary Rating of

Health Plan QualityPlan too new to be measured

This summary rating gives an overall score on the health plan’s quality and

perormance on 33 dierent topics in 5 categories:

• Staying healthy: screenings, tests, and vaccines. Includes how oten

members got various screening tests, vaccines, and other check-ups that

help them stay healthy.

• Managing chronic (long-term) conditions. Includes how oten members with

diferent conditions got certain tests and treatments that help them manage

their condition.

• Ratings o health plan responsiveness and care. Includes ratings o member

satisactions with the plan.

• Health Plan member complaints, appeals, and choosing to leave the health

plan. Includes how oten members have made complaints against the plan

and how oten members choose to leave the plan.

• Health plan telephone customer service. Includes how well the plan handles

member calls.




Medicare Prescription Drug Plan Ratings

The Medicare Program rates how well Medicare Prescription Drug Plans perorm in diferent categories (or

example, customer service, drug pricing, patient saety). The inormation provided below is a summary rating

o our plan’s overall perormance. This inormation is available to help you make the best choice. I you would

like to get additional inormation on our plan’s perormance please contact us at 1-800-547-5514 (toll-ree)

or 711 (TTY/TDD) or prospective members, 1-800-643-4845 (toll-ree) or 711 (TTY/TDD) or current

members, or you may visitt www.medicare.gov.

Below is a summary o how our plan rated in quality and perormance.

The number of stars show how well our plans perform. means excellent means very good means good means air means poor


Summary Rating of

Prescription Drug

Plan Quality

Not enough data to calculate summary score

This summary rating gives an overall score on the drug plan’s quality and

perormance on 19 dierent topics in 4 categories:

• Drug plan customer service: Includes how well the drug plan handles calls

and makes decisions about member appeals.

• Drug plan member complaints, members who choose to leave, and

Medicare audit fndings: Includes how oten members complain about

the drug plan and how oten members choose to leave the drug plan.

• Member experience with drug plan: Includes member satisaction inormation.

• Drug pricing and patient saety: Includes how well the drug plan prices

prescriptions and provides accurate pricing inormation on the Medicare

website. Includes inormation on how oten members with certain medical

conditions get prescription drugs that are considered saer and clinically

recommended or their condition.

This inormation is gathered rom several dierent sources, including results

rom Medicare’s regular monitoring activities, reviews o billing and other

inormation that plans submit to Medicare, and Medicare’s member surveys.



What Dental Benets DoI Receive?With the Platinum Rider, you get:

• 100% coverage for preventive and diagnosticservices such as oral exams, X-rays and routinecleanings. Partial coverage for basic servicessuch as llings and for major services such ascrowns, dentures, root canals and oral surgery.

There is a $100 member deductible and a $1,000calendar year maximum. Deductible does not applyto preventive and diagnostic services.

Can I See Any Dentist?Choose your dentist from a large national networkof providers. You may change network dentists atany time however you will need to complete anydental service currently in progress. Please seeyour Provider Directory for a listing ofparticipating dentists.

When you receive your Covered Dental Servicesfrom an Out-of-Network Dentist, the plan paysaccording to a Maximum Allowable Fee Schedule*.You pay all fees in excess of this amount.

Please refer to your Evidence of Coverage to learnmore about the full range of covered services,including a dental procedural and fee chart.

How Do I Enroll?You must be enrolled in a SecureHorizons® health

plan in order to purchase a rider. Purchasing a rideris optional. Please contact Customer Service at thenumber listed on the back of your Member ID Cardto enroll in a rider.

When is the EnrollmentEfective Date?

If your completed enrollment request is receivedby the last day of the month, your benets will beeective the rst day of the following month. Forexample, if you call Customer Service and enroll onMarch 31, your benets will begin on April 1.

If you are an existing plan member, you may enrollany time during the year. Please note that you can’tbe enrolled in more than one dental rider at a timeduring the calendar year, including the Deluxe Rider.

Dental Platinum RiderIf you’re looking for extra dental protection and coverage, our SecureHorizons® optional supplemental

dental rider may be right for you. The Platinum Rider is available for an additional monthly premium

of $32.

*Allowable Fee Schedules vary according to geographic area and is a set amount that may not be equal to theDentist’s full fee. For further details, please contact Customer Service. Y

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AAEX11MP3244438_000

The benet inormation provided herein is a brie summary, not a comprehensive description o benets. For

more inormation contact the plan.

The AARP® MedicareComplete® plans are SecureHorizons® plans insured or covered by an afliate o

UnitedHealthcare Insurance Company, a Medicare Advantage organization with a Medicare contract. AARP

MedicareComplete plans carry the AARP name, and UnitedHealthcare pays a royalty ee to AARP or use o the

AARP intellectual property. Amounts paid are used or the general purpose o AARP and its members. AARP is

not the insurer. You do not need to be an AARP member to enroll. AARP does not recommend health related

products, service insurance or programs. You are strongly encouraged to evaluate your needs.



Take advantage o the ollowingSilverSneakers® services:• A basic tness center membership at over

10,000 participating locations.

• Access to cardio equipment, resistance

machines, free weights and a heated pool

at certain locations.

• SilverSneakers classes for Medicare-eligible

beneciaries who want to improve their strength,

exibility, balance and endurance (available atselect locations).

• Access to any participating tness center while

traveling throughout the United States.

To nd participating locations in your area, please

visit www.SilverSneakers.com.

The SilverSneakers® Fitness Program is a winner of

the 2004 Healthcare and Aging Network Award of

the American Society on Aging.

How Do I Enroll?You must be enrolled in a SecureHorizons® health

plan in order to purchase a rider. Purchasing a rider

is optional. Please contact Customer Service at the

number listed on the back of your Member ID Card

to enroll in a rider.

When is the EnrollmentEfective Date?If your completed enrollment request is received

by the last day of the month, your benets will beeective the rst day of the following month. For

example, if you call Customer Service and enroll on

March 31, your benets will begin on April 1.

SilverSneakers® Fitness RiderThe SilverSneakers® Fitness Rider can help you take charge of your health and maintain an active

lifestyle. This award-winning program is available for an additional $13 monthly premium.

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The benet inormation provided herein is a brie summary, not a comprehensive description o benets. For

more inormation contact the plan.

SilverSneakers® is a registered trademark o Healthways, Inc. Healthways, Inc., is an independent company.

Consult a health care proessional beore beginning any exercise program.

The AARP® MedicareComplete® plans are SecureHorizons® plans insured or covered by an afliate o

UnitedHealthcare Insurance Company, a Medicare Advantage organization with a Medicare contract. AARP

MedicareComplete plans carry the AARP name, and UnitedHealthcare pays a royalty ee to AARP or use o the

AARP intellectual property. Amounts paid are used or the general purpose o AARP and its members. AARP is

not the insurer. You do not need to be an AARP member to enroll. AARP does not recommend health related

products, service insurance or programs. You are strongly encouraged to evaluate your needs.



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2011 Disclaimers

Your Plan may contain one or more o the ollowing:

NurseLineSM

OptumHealthSM is a health and well-being company that provides inormation and support as part o your

health plan. NurseLine

SM

nurses cannot diagnose problems or recommend specic treatment and are not asubstitute or your doctor’s care. NurseLineSM services are not an insurance program and may be discontinued

at any time.

SilverSneakers®

SilverSneakers® is a registered trademark o Healthways, Inc. Healthways, Inc., is an independent company.

The SilverSneakers® program is made available as part o this Plan’s benets to those insured through this

Plan. Neither AARP nor UnitedHealthcare endorse or are responsible or the services or inormation provided

by this program. Consult a health care proessional beore beginning any exercise program.

Silver & Fit

Silver & Fit is provided by American Specialty Health Networks, Inc. and Healthyroads, Inc., subsidiaries oAmerican Specialty Health Incorporated.

Evercare™ Hospice

Evercare™ Hospice and Palliative Care is committed to the policy that all persons shall have equal access

to its programs, acilities, and employment without regard to race, sex, religion, color, age, national origin,

disability, sexual orientation or other protected actor. Evercare™ Hospice and Palliative Care is oered by

Evercare Hospice, Inc.

General Information

Benets, ormulary, pharmacy network, premium and/or co-payments/co-insurance may change on

January1, 2012.

The benet inormation provided herein is a brie summary, not a comprehensive description o benets.

For more inormation contact the Plan.

This document is available in alternate ormats or languages. For more inormation please contact the Plan at

1-800-547-5514, TTY: 711, 8 a.m. to 8 p.m., 7 days a week.

Este documento está disponible en dierentes ormatos o idiomas. Para obtener más inormación, por avor

comuníquese con el Plan llamando al 1-800-547-5514, TTY: 711, de 8:00 a.m. a 8:00 p.m.,

los 7 días de la semana.

本文件可以其他形式或語言提供。如需更多資訊，請與本計劃聯絡，電話號碼是

1-800-547-5514，TTY: 711，每週七天，上午八時至晚上八時。

Plan is insured or covered by UnitedHealthcare Insurance Company or one o its afliates, a Medicare

Ad anta e Or ani ation ith a Medicare contract

2011 Plan Description

Documents

Transcript of 2011 Plan Description